Survey data of public in Sindh Pakistan regarding willingness to accept COVID-19 vaccination

Objective The COVID-19 pandemic has badly affected the world with its devastating effects, including Sindh, Pakistan. A massive vaccination campaign against COVID-19 is considered one of the effective ways to curtail the spread of the disease. However, the acceptability of the COVID-19 vaccine is based on the general population’s knowledge, attitude, perception and willingness for vaccination. Therefore, a survey among the public in Sindh, Pakistan, was done to evaluate their knowledge, attitude, perception and willingness to accept COVID-19 vaccination. Method The online survey was conducted among the residents of Sindh, Pakistan, in July 2021 through a survey tool designed using Google Forms and sent to the population through various social media. Results Of 926 study participants, 59.0% were male, and 68.6% were aged between 18 and 31 years. Higher percentages of responses were recorded from the Hyderabad division (37.5%), and 60.0% of respondents were graduates, with 34.8% of them in the private sector. The results showed that 36.4% of respondents had good knowledge, and 30.3% had a positive attitude toward COVID-19 vaccination. Almost 77% of respondents perceived that everyone should get vaccinated in the country and those health care workers on priority. A majority (80.8%) of respondents were willing to accept COVID-19 vaccination. Conclusion Despite having insufficient knowledge and a low percentage of positive attitude public in Sindh are willing to be vaccinated. Based on this finding, more effort has to be done to promote vaccination among the public, especially among the less educated population.

Introduction studies [17][18][19]. Then, the initial draft of the survey was designed in English and Urdu using Google Forms and was shared with a team of three academic experts in the research area. After their consultation and consensus, the final version of the survey was designed and underwent a pilot study consisting of 50 respondents for content validation and reliability. The internal reliability of the pilot study was tested through Cronbach's alpha coefficient using SPSS v22. The value of Cronbach's alpha for the survey was 0.691. The survey instrument was designed using Google Forms with an appended consent statement, and the link was promoted through various social media contacts and groups, including Facebook, WhatsApp and Telegram. The respondents were also encouraged to share the link with their contacts, and so on. The respondents received information about the research study and informed consent by clicking the provided link. Once they agreed to participate in the online survey, they had to fill in the demographic information. Then, several questions based on their knowledge, attitude, perception and willingness to accept the COVID-19 vaccine appeared which were to be responded, sequentially. The online survey was open to; 1) all the residents of the province of Sindh, Pakistan, 2) respondents aged �18 years, and 3) those who had internet facilities and could understand either English or Urdu. The participants could fill out and submit it using a computer or cell phone. The participants could fill out the survey in around 5-7 minutes. Initially, a sum of 1044 responses was recorded during the study period. Of them, 926 respondents had filled out the survey altogether, which gave a response rate of 88.69%.

Measures
The online survey included information based on research background, motivations, confidentiality statement, voluntary contribution, and items based on their knowledge, attitude, perception and willingness to accept vaccination against COVID-19. The questionnaire contained 7 questions on respondents' demographic information, including; gender, age, marital status, residential area, division of residence, academic qualification and profession. There were 2 questions regarding the personal history of COVID-19 infection and any death reported from family members, relatives and friends due to COVID-19 infection. And then, there were 17 items regarding the knowledge, attitudes, perception and willingness toward the acceptability of the COVID-19 vaccine.

Knowledge, attitudes, perception and willingness to accept COVID-19 vaccine
The knowledge portion consisted of seven questions that led to an awareness of the COVID-19 vaccine, its effectiveness and spectrum of efficacy, side reactions, and degree of protection after vaccination. The answers were either "No" or "Yes" assigned dichotomous responses. 1 point was given for each correct answer and 0 points for each wrong answer. The overall outcome of the knowledge score was measured by summing all the values. Consequently, respondents having a knowledge score higher than the mean were considered to have "Good Knowledge", those having equaled to mean were considered to have "Average Knowledge", and those having less than the mean were considered to have "Poor Knowledge".
Respondents' attitudes were measured by four statements based on their belief in government-provided vaccinations, encouraging others to vaccination and the spread of COVID-19 after vaccination. All statements were rated on a 5-point Likert scale, including Strongly disagree (1-point), Disagree (2-points), Neutral (3-points), Agree (4-points) and Strongly agree (5-points). The total attitude score was measured by summing up all the values. Accordingly, the respondent with attitude scores higher than the mean, equal to the mean and less than the mean were counted to reflect positive, neutral, and negative attitudes, respectively. Three statements assessed respondents' perception: the possibility of side effects due to the COVID-19 vaccine, control of COVID-19 spread without vaccination, and chances of COVID-19 after vaccination. Every statement was assigned five options, including Strongly disagree (1-point), Disagree (2-points), Neutral (3-points), Agree (4-points) and Strongly agree (5-points). Two additional statements regarding respondents' perceptions were: "According to you, who should get vaccinated?" and "What do you think, who should get vaccinated on priority?" A single choice statement analyzed respondents' willingness to accept the COVID-19 vaccine; "No or Yes".

Statistical analysis
Data was generated using Statistical Package for Social Sciences version 22.0 (SPSS v.22 from IBM Corporation, Armonk, NY). Continuous variables were expressed as Means ± standard deviations. However, categorical variables were expressed in frequencies and percentages. A comparison of knowledge and attitude levels was made through Chi-square tests for different groups of variables. Kruskal Wallis tests and Mann Whitney U tests were applied to compare the mean knowledge and attitude scores among different group variables. All p-values less than or equal to 0.05 was considered significant. Multinomial logistic regression was performed to predict the factors responsible for accepting the COVID-19 vaccine among respondents.

Ethical approval
This research was ethically approved by the Institutional Bioethics Committee (IBC), University of Sindh, Jamshoro, Pakistan (Ref. No. ORIC/SU/845). Anonymity and confidentially were highly maintained during the process of data collection.

Results
Out of 926 respondents, 59.0% were male, and around 2/3 rd respondents, 68.6%, were lying in the age group between 18 and 31 years. The average age of the respondents (mean ± SD) was 28.9±8.9. More than half, 59.9%, of respondents were single, and belonged to urban areas (60.4%). Higher response percentages were recorded from Hyderabad, Mirpurkhas, and Karachi divisions as 37.5%, 17.8% and 16.6%, respectively. Approximately 60.0% of respondents held a graduation degree, and around one third (34.8%) were doing a private job. Only 13.5% of respondents reported getting an infection of COVID-19, and 27.6% of respondents had lost their family members/relatives/friends due to COVID-19 infection (Table 1).

Respondents' knowledge for COVID-19 vaccination
The average knowledge score (mean ± SD) was 5.03 ± 1.11. A large majority of respondents, 93.4% were familiar with the COVID-19 vaccine, 83.4% were aware of the efficacy of the COVID-19 vaccine, and 46.1% had believed in the vaccine's effectiveness against different COVID-19 variants. Around 85.4% of respondents thought that an overdose of the vaccine could be dangerous for life, 68.4% believed that the COVID-19 vaccine could cause allergic reactions, 27.3% thought that the COVID-19 vaccine might be responsible for autoimmune diseases, 53.1% had believed that despite being vaccinated they could be the source of spreading COVID-19. Furthermore, about 1/3 rd of respondents, 36.4%, had good knowledge of the COVID-19 vaccine, as presented in Table 2.

Respondents' attitude for COVID-19 vaccination
The average (mean ± SD) score for attitude for COVID-19 vaccination was 18.61 ± 3.82. Nearly half, 48.6% of the respondents believed that the vaccine provided by the Government of Pakistan was very safe, 51.0% agreed that everyone should get vaccinated against COVID-19, and 31.9% of respondents strongly agreed to recommend vaccination of their family members, relatives, and friends against COVID-19. Approximately 40% of respondents strongly agreed that the incidences of COVID-19 cannot be reduced without vaccination. Overall, 30.3% of surveyed respondents had a positive attitude toward the COVID-19 vaccine, as described in Table 3.

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Public's willingness to accept COVID-19 vaccination that COVID-19 could be eradicated without a vaccine if everyone adopts precautionary measures, and 19.4% perceived that there was a low risk of COVID-19 after being vaccinated. Around 3/4 th of respondents, 77.0% had perceived that everyone in the country should get vaccinated, and 77.6% perceived that the health care professionals should be vaccinated on priority (Table 4).

Respondents' willingness to accept COVID-19 vaccination
Regarding the willingness to accept the COVID-19 vaccine, 748 (80.8%) respondents were very willing to be vaccinated, offered by the government without any hesitation. Whereas only 178 (19.2%) were reluctant to get vaccinated against COVID-19, as shown in Fig 1.

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Public's willingness to accept COVID-19 vaccination years. Additionally, having a graduation degree was another contributing factor to accepting COVID-19 vaccine, which was approximately seven times more than primary and matriculation respondents OR: 7.11 [95% CI, 1.6-29.9].

Inferential analysis of status of knowledge and attitude versus respondents' characteristics
The associations of the status of knowledge and attitudes with respondents' characteristics were determined by applying a chi-square test. Regarding the status of knowledge, there was no significant difference among the gender and age groups. Nevertheless, there were substantial differences when comparing the status of knowledge within divisions (p = 0.011), academic qualification (p = 0.001) and profession (p = 0.035). Similarly, while comparing attitude status,

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there was no significant difference between gender and age groups. However, there was a marked difference with different groups of divisions (p = 0.043), academic qualification (p = 0.007) and profession (p = 0.012), as shown in Table 6.

Comparison of knowledge and attitude among different demographic groups
The average knowledge and attitude scores (mean ± SD) were determined for different variables, including gender, age group, marital, division, education and profession. There was no substantial difference in knowledge scores among different variable groups except among the respondents from various divisions (p = 0.013) ( Table 5). Kruskal Wallis tests and Mann-Whitney U was applied to compare the mean knowledge and attitude score among different groups of variables. There was a noteworthy difference

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(p = 0.013) in knowledge scores among the respondents from different divisions. Accordingly, the attitude score from variable including age groups (p = 0.006), division (p = 0.050), education (p = 0.012) were predominantly different within their groups (Table 7).

Discussion
There is a unanimous consensus among world health experts that a massive global vaccination drive against COVID-19 is the ultimate solution to curtail this deadly pandemic. Infectious diseases may be prevented by the safe and effective use of vaccines [20]. However, delaying and denying vaccination has been a perplexing problem observed in the general population worldwide. Meanwhile, sufficient knowledge, appropriate attitude and positive perception of the COVID-19 vaccine may be essential to its acceptability [21]. Therefore, this research study was performed to assess the knowledge, attitude, and perception toward the COVID-19 vaccine in the population of Sindh, Pakistan. This assessment is crucial to assist the government authorities in educating the vulnerable groups about getting vaccinated throughout the country, mainly in the province of Sindh, which has recorded the highest number of COVID-19 cases in Pakistan. Our study discovered that only 36.4% and 30.3% of respondents had good knowledge and positive attitude towards COVID-19 vaccines, whereas 77.0% of respondents perceived that everyone should get vaccinated against the COVID-19 vaccine offered by Government.
Our study findings suggest that only 36.4% of respondents had good knowledge regarding the COVID-19 vaccine. This lower ratio of knowledge of vaccines could be associated with lower education standards in Sindh, lack of information about vaccines, and the influence of social media posting an impact on the decision-making process [19]. However, in our study, middle-aged respondents, specifically residents of big cities, diploma holders, doing private

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jobs were the determinate factors of higher average knowledge. Moreover, studies from Pakistan [22] and Egypt [23] have reported that older participants aged 50 to 59 years had low knowledge. In a study conducted in West India, only 35.5% of respondents had good knowledge [10], where lack of education has been one factor for lower knowledge rates. Understanding the implications of epidemiological control of the disease and the effectiveness and progress of the vaccination drives requires a positive attitude of the general population toward the COVID-19 vaccines. Only 30.3% of respondents had a positive attitude toward COVID-19 vaccination in this study. The findings were consistent with a previous study from Sindh, Pakistan [3], which reported a similar level (34.88%) of a positive attitude toward COVID-19 among study respondents. There is a correlation between positive attitudes and acceptance of COVID-19 vaccination. This correlation may be because highly educated people remain more conscious of their health and well-being and are more involved in life events that may affect them, such as COVID-19 vaccinations. However, low-literacy rates and limited access to smartphones and the internet in rural areas of Sindh might be the contributing factors toward KAP [3].
It is estimated that 75-90% of vaccine coverage is required to achieve herd immunity [24]. It is necessary to understand the perception and sensitivity of the population towards vaccination to achieve such a higher coverage. Here we report that nearly half (48.6%) of the respondents had agreed that the COVID-19 vaccine provided by the Government of Pakistan was very safe. It has been reported that the primary concern undermining the positive attitude towards vaccination is that the new vaccines will not be safe [25,26]. Therefore, it is suggested that disseminating factual information about the safety and effectiveness of COVID-19 vaccines is highly recommended to ensure their acceptability and coverage.
Regarding respondents' perception of COVID-19 vaccination, about a third (33.0%) of the respondents believed that the COVID-19 vaccine might have serious side effects. The majority of respondents (42%) agreed that taking all precautions could eliminate COVID-19 without a COVID-19 vaccine. Additionally, around one-fifth of respondents (19.4%) believed that they were less likely to be infected with COVID-19 after vaccination. The fact behind misconception is based on the spread of myths about COVID-19 vaccines through social networks [27,28]. Similarly, a study from Saudi Arabia reported that 23.4% of the participants believed that there was a chance of infection after vaccination [29]. A survey from Delhi, India, has reported that 65.7% of study participants believed that they can still be infected after vaccination which was far more than what was found in our study [30]. A Malaysian cross-sectional study reported that more than half of the participants were worried about the vaccine's adverse effects [31]. It was also found that the majority of study respondents believed that vaccines protect themselves and others who are unvaccinated.

Limitations of study
There are a few limitations in current research. Firstly, this study is limited only to a single province, limiting the generalizability of the results. Secondly, the study was based on an online survey; hence the response depends primarily on honesty and partly on the ability to recall. Finally, being an online survey, this study, by its nature, excludes the participants of nations who do not have access to the internet and the availability of smartphones or laptops.

Conclusion
The Sindh population should be improved in understanding related issues to the COVID-19 vaccination process. Our research study concludes that respondents aged between 18 and 31 years, private jobholders, students, and post-graduates had sound knowledge about vaccines.
The data also shows that vaccine acceptance was more among the older age group and higher qualification levels. However, there was no such impact of the profession on the acceptability of COVID-19 vaccines. Despite insufficient knowledge and a low percentage of positive attitudes, people are willing to take COVID-19 vaccines. However, the government needs to take further proactive steps to promote the information regarding the misconceptions about the COVID-19 vaccine and encourage the vulnerable groups to get vaccinated.